Phillylacrosse.com, Posted 12/20/12
From Press Release

The Penn State men’s lacrosse program will hold a free boys’ lacrosse clinic on Sunday, Jan. 13, 2013 at Holuba Hall. The free clinic, co-hosted with Centre Lacrosse, is to develop youth lacrosse across Central Pennsylvania.

Head coach Jeff Tambroni, his staff and members of the team will work with boys aged 12 and under from 9:15-10:15 a.m. on Jan. 13. At 10:30, boys 13 and over will be a part of a clinic until Noon.

Participants will need a signed clinic registration form and full lacrosse equipment, including mouth guard. Please contact volunteer assistant coach David Shriver (djs74@psu.edu) for more information.

Details
Sunday January 13, 2013 in Holuba Hall at Penn State University Park
9:15 am to 10:15 am: Boys ages 12 and under
10:30 am to Noon: Boys ages 13 and over
Click here for event website

2013 PENN STATE CLINIC REGISTRATION FORM
BRING FORM TO REGISTRATION ON THE DAY OF THE CLINIC.

Sport: ______________________ Date: ______________
_____________________________________________________________________________________
Last name First name Birth date (m/d/y) Age
______________________________________________________________________________
Home Address (Street, City, State, Zip)
______________________________________________________________________________
Parent’s/Legal Guardian’s Name Home Phone Cell Phone
RELEASE
I, the undersigned, as a parent or legal guardian of_______________________________,
a minor, ask that he/she be admitted to participate in this clinic sponsored by The Pennsylvania State
University. In consideration of such admission, I do hereby agree to release, discharge, and hold harmless
The Pennsylvania State University, its officers, agents, and employees of and from all causes, liabilities,
damages, claims, or demands whatsoever on account of any injury or accident involving the said minor
arising out of the minor’s attendance at the clinic, or in the course of competition and/or activities held in
connection with the clinic.
Additionally, I authorize Penn State to photograph, videotape, and/or audiotape my child in promotion of the
University’s clinics.

MEDICAL TREATMENT AUTHORIZATION
I hereby authorize the clinical staff of University Health Services or other licensed practitioner of the healing
arts, acting within the scope of his or her practice under State law, to provide medical care that includes routine
diagnostic procedures (e.g., x-rays, blood and urine tests) and medical treatment as necessary to my minor
daughter/ son/dependent.

I understand that the consent and authorization herein granted do not include major surgical procedures
and are valid only during the program activities/camp.
Child’s physical or emotional health conditions that the clinician should be aware of: ____________
allergies________________________________________________________________________,
recurring illnesses, disabilities, chronic illnesses, etc.:
______________________________________________________________________________
medications____________________________________________________________________,
Date of most recent tetanus immunization: ____________________________________________
(If more than ten years ago, a booster shot is recommended.)
______________________________________________________________________________
Name of emergency contact Phone no.
In the event that an illness or injury would require more extensive evaluation, I understand that every
reasonable attempt will be made to contact me. However, in the event of an emergency and if I cannot be
reached, I give my consent for physicians and staff at University Health Services or other licensed
practitioners of the healing arts to perform any necessary emergency treatment. I agree to the release of
any records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care
provider. I understand that University Health Services does charge for services and that it is my
responsibility to pay the bill. As applicable, I am responsible to submit any claims to my health insurance
company for reimbursement.
I understand that, unless specifically stated otherwise in the Penn State program/camp literature, The
Pennsylvania State University does not provide medical insurance to cover emergency care or medical
treatment of my child.
Signature requested:
__________________________________________________________________________
Parent’s/Legal guardian’s signature Date

In accordance with NCAA guidelines, all Penn State University Sport Camps and Clinics are open to any and all
entrants, limited only by specified number, age, grade level and/or gender of its participant.